AUTHORIZATION, CONSENT, AND RELEASE FORM ELECTROMYOGRAPHY (EMG) AND
NERVE CONDUCTION STUDY (NCS)
Electromyography (EMG) and Nerve Conduction Study (NCS) are diagnostic procedures used
to assess the health of muscles and the nerve cells that control them (motor neurons). These
tests help detect nerve or muscle dysfunction and problems with nerve-to-muscle signal
transmission. During EMG, small needle electrodes are inserted into muscles to record electrical
activity. During NCS, your nerve is stimulated electrically to measure response and conduction
speed. You may experience brief discomfort, tingling, or twitching. Risks include mild pain,
bruising, or bleeding at insertion sites; serious complications such as infection or nerve injury
are rare.
AUTHORIZATION AND CONSENT
I authorize and direct the physician(s) listed above and staff to perform EMG and NCS, as well
as any other diagnostic or therapeutic procedures deemed advisable in their professional
judgment. I understand the nature, purpose, benefits, and risks of the procedures, and that no
guarantees have been made regarding results. I acknowledge I may refuse or withdraw consent
at any time. I consent to the performance of emergency procedures deemed necessary by the
physicians in the event of an unexpected complication during EMG/NCS testing.
HIPAA NOTICE AND CONTACT PREFERENCES
In accordance with HIPAA Privacy Rules, I acknowledge receipt of the Notice of Privacy
Practices and understand my rights to request restrictions or alternative methods of
communication regarding my protected health information (PHI). Preferred contact methods
(check all that apply):
AUTHORIZATION TO RELEASE RECORDS
I authorize the release of my medical records to my referring physician and to the physician(s)
listed above for purposes of coordination of care and billing. Reports will be forwarded to the
referring physician within 2 business days of testing.
INSURANCE PAYMENT AUTHORIZATION
I authorize my insurance company to make payments directly to the physician(s) listed above for
services rendered. This payment shall not exceed my indebtedness for those services. I agree
to pay any remaining balance. I understand a $50 monthly late fee and a $15 statement fee may
apply to unpaid balances. PATIENT CONSENT FOR USE OF CREDIT/DEBIT CARD OR
FINANCING
I consent to the use and disclosure of my protected health information to process payments via
credit card, debit card, or third-party financing. I understand that once services are rendered, I
will not dispute these transactions. I acknowledge this consent is irrevocable. I understand I am
financially responsible for all services not covered by insurance, including deductibles,
co-insurance, and amounts exceeding insurance payments. I understand a $50 monthly late fee
and a $15 statement fee may apply to unpaid balances. I agree to comply with my insurer’s
referral and pre-authorization requirements to avoid claim denials.
ARBITRATION AGREEMENT
Any dispute as to medical malpractice, whether services rendered were unnecessary,
unauthorized, or negligently provided, shall be determined by arbitration in accordance with California law and the Medical Arbitration Rules of the California Hospital Association – California Medical Association. This arbitration agreement shall apply to any legal claim or civil action in connection with this outpatient service against the Center or its employees and any doctor of medicine who has agreed, at the time of your admission as evidence by written agreement in the physician’s medical staff file to be bound by this provision, unless patient or undersigned initial below or unless rescinded a written notice within 30-days of signature. An agreement to arbitrate shall not be a precondition to the rendering of services under this agreement. Patients may decline arbitration by NOT initialing below or rescinding within 30
days. BY INITIALING THESE CONDITIONS OF TREATMENT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY/COURT TRIAL.
I have read and understood all of the information provided above, and all of my questions have
been answered to my satisfaction. By signing below, I acknowledge and consent that
I have read and initialled each section above.
